Wisconsin In-Network Transportation Provider Checklist

Date: __________________________LogistiCare EDI User FormPlease Type or Print ClearlyProvider Name: ______________________________________________________________Mailing Address: ___________________________________________________________________________________________________________________________Phone Number: _____________________ Fax Number: _____________________LogistiCare Provider Number (Shorthand): ______________________Access: Select one from the left column and one or more from the right column: Add New User LogistiCare TP Web Site Inactivate User Provado Dispatch and Billing Mgr. Re-activate Existing User Login Password ResetUser Last Name: ___________________________________________User First Name: ___________________________________________User Title:___________________________________________Authorized Signature: __________________________________________________________(From Operational Information Form)Fax to:Provado Technologies / Attn: LogistiCare TP ServicesFax Number: 904-737-8104NOTE: For a new user, this form will be completed by Provado Technologies and faxed back tothe fax number provided at the top. Please be sure to supply a fax number where the return faxcan be secured until given to the user.TO BE COMPLETED BY PROVADO TECHNOLOGIES, LLC:User ID Assigned:Temporary Password:Date Completed:___________________________________________________________________________________________________________________________Page 64